Healthcare Provider Details

I. General information

NPI: 1699899187
Provider Name (Legal Business Name): NORTHWESTERN COUNSELING & SUPPORT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 11/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 FISHER POND ROAD
SAINT ALBANS VT
05478-6286
US

IV. Provider business mailing address

107 FISHER POND ROAD
SAINT ALBANS VT
05478-6286
US

V. Phone/Fax

Practice location:
  • Phone: 802-524-6554
  • Fax: 802-524-6562
Mailing address:
  • Phone: 802-524-6554
  • Fax: 802-524-6562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. TED JOHN MABLE
Title or Position: EXECUTIVE DIRECTOR
Credential: ED.D.
Phone: 802-524-6555